1598916553 NPI number — CENTER FOR COLON AND DIGESTIVE CARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598916553 NPI number — CENTER FOR COLON AND DIGESTIVE CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR COLON AND DIGESTIVE CARE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORTHSIDE MEDICAL SPECIALISTS, LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598916553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 REINHARDT COLLEGE PKWY
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30114-5257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-704-9499
Provider Business Mailing Address Fax Number:
770-704-9754

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 SAMMY MCGHEE BLVD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30143-7721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-692-6566
Provider Business Practice Location Address Fax Number:
706-692-3896
Provider Enumeration Date:
10/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SWAFFORD
Authorized Official First Name:
CHRISTINA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
770-704-9499

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  046761 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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